Wheezing
Samir S. Shah
Approach to the Patient with Wheezing
I. Definition of the Complaint
Noisy breathing, as opposed to the usual silent breathing patterns of infants,
is a common presenting complaint. The first step in formulating a differential
diagnosis is to characterize the type of sound heard. Stertor, a rattling
inspiratory noise, is frequently heard in infants with nasal congestion.
Stridor, a harsh, high-pitched respiratory sound typically heard on
inspiration, often indicates laryngeal obstruction. Wheezing, a musical sound
heard on expiration, is caused by partial obstruction of the lower airway. In
young children, sometimes expiratory noises cannot be easily distinguished from
inspiratory ones, and at times both may be present. Among these causes of noisy
breathing, wheezing is the most common.
II. Complaint by Cause and Frequency
The causes of wheezing in childhood vary by age (Table 1-1) and may also be
grouped in categories based on the following mechanisms: (a) anatomic
(extrinsic or intrinsic to the airway), (b) inflammatory/infectious, (c)
genetic/metabolic, or (d) miscellaneous causes (Table 1-2).
III. Clarifying Questions
Thorough history taking is essential to arriving at an accurate diagnosis in a
child who presents with wheezing. Consideration of age at onset, course and
pattern of illness, and associated clinical features provides a useful
framework for creating a differential diagnosis. The following questions may
help provide clues to the diagnosis.
• What was the age at onset of wheezing?
— Onset at birth or during early infancy suggests congenital structural
abnormalities. Congenital diaphragmatic hernias (CDHs) are usually detected on
prenatal ultrasound. Vascular rings and aberrant vessels can cause wheezing or
other respiratory symptoms early in life. Infants younger than 2 years of age
are more susceptible to lower respiratory tract infection (e.g.,
bronchiolitis), whereas adolescents are more likely to have asthma or
Mycoplasma pneumoniae infection.
• Is the wheezing of new onset or recurrent?
— The initial episode of wheezing in a previously healthy infant in conjunction
with symptoms of upper respiratory tract infection usually indicates
bronchiolitis. The sudden onset of wheezing is also characteristic of
anaphylaxis; particularly in the presence of urticaria, stridor, or
environmental exposure. Recurrent episodes of wheezing may suggest
gastroesophageal reflux (GER). However, if precipitated by upper respiratory
infections, recurrent wheezing may suggest reactive airways disease. Recurrent
wheezing or
“difficult-to-control asthma” should lead to consideration of cystic fibrosis, immotile cilia syndrome,
recurrent aspiration, immune deficiency, or anatomic abnormalities.
• Is the wheezing episodic or persistent?
— Persistent wheezing suggests mechanical obstruction from a variety of causes,
such as airway foreign body, congenital airway narrowing, or external
compression by a mediastinal mass or vascular anomaly.
• Was the episode of wheezing preceded by choking or gagging?
— Aspiration of a foreign body is sometimes associated with the sudden onset of
symptoms after gagging or choking. Foreign body aspiration is most common in
children between the ages of 1 and 4 years. Symptoms depend on the size and
location of the foreign body. The wheezing may be unilateral, and secondary
bacterial infection may occur.
• Was the wheezing preceded by upper respiratory tract infection?
— Antecedent upper respiratory tract infection is suggestive of an underlying
inflammatory or infectious etiology.
• What is the child's weight and height?
— Features suggestive of cystic fibrosis include failure to thrive, steatorrhea,
and recurrent infections.
• Is there a history of recurrent bacterial infection?
— Children with cystic fibrosis often have recurrent respiratory tract
infections. Ciliary dyskinesis is associated with frequent cough, sinusitis,
and otitis media.
• Is there a history of preterm birth, or did the child require mechanical
ventilation or prolonged supplemental oxygen after birth?
— Bronchopulmonary dysplasia should be considered.
• Does the patient have allergic shiners, Dennie lines, nasal crease, or atopic
dermatitis?
— The presence of atopy increases the likelihood of asthma.
• Are symptoms exacerbated by feeding?
— GER and tracheoesophageal fistula (TEF) should be considered.
• Was the mother tested for sexually transmitted diseases during pregnancy?
— Chlamydia trachomatis pneumonia may present during the 2nd month of life, with nonpurulent
conjunctivitis, wheezing, and pneumonia without fever.
The following cases represent less common causes of wheezing in childhood.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Wheezing
Read excerpts from these other book chapters related to Wheezing:
Medical Books Excerpts
- STRIDOR
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- WHEEZING
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Stridor
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Wheezing
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
- Stridor
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Wheezing
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Stridor
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Stridor
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Wheezing
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Stridor
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Wheezing
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Stridor
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Wheezing
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Wheezing
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Stridor
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- WHEEZING
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Wheezing
- "Pediatric Complaints and Diagnostic Dilemmas" (2003)
- [ read ]
Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Wheezing
» Next page: Wheezing - Case 1-1: 8-Month-Old Girl (Pediatric Complaints and Diagnostic Dilemmas)
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